MR-CRAS

Introduction and disclaimer

MR-CRAS is a new clinically and construct validate, structured short-term risk assessment instrument called the Mechanical Restraint–Confounders, Risk, Alliance Score (MR-CRAS), with the intended purpose of supporting the clinicians’ observation and assessment of the patient’s readiness to be released from mechanical restraint.

Disclaimer: MR-CRAS is currently being further developed so that items paired with conflict and risk management strategies can be used by clinicians in order to facilitate decisions in regard to discontinuation of mechanical restraint. Current version does not contain such conflict and risk management strategies and has therefore not be effect tested for its ability to reduce time spend in mechanical restraint. Future advancements and developments will be made available on this web page.

Unstructured risk assessment, as well as confounders (underlying reasons for the patient’s risk behaviour and alliance), risk behaviour, and parameters of alliance, have been identified as factors that prolong the duration of mechanical restraint among forensic mental health inpatients. Aim: To clinically validate a new, structured short-term risk assessment instrument called the Mechanical Restraint–Confounders, Risk, Alliance Score (MR-CRAS), with the intended purpose of supporting the clinicians’ observation and assessment of the patient’s readiness to be released from mechanical restraint. The content and layout of MR-CRAS and its user manual were evaluated using face validation by forensic mental health clinicians, content validation by an expert panel, and pilot testing within two, closed forensic mental health inpatient units. The three sub-scales (Confounders, Risk, and a parameter of Alliance) showed excellent content validity. The clinical validations also showed that MR-CRAS was perceived and experienced as a comprehensible, relevant, comprehensive, and useable risk assessment instrument. Conclusions: MR-CRAS contains 18 clinically valid items, and the instrument can be used to support the clinical decision-making regarding the possibility of releasing the patient from mechanical restraint. Implications: The present three studies have clinically validated a short MR-CRAS scale that is currently being psychometrically tested in a larger study.

One of the main reasons for prolonged duration of mechanical restraint is patient behaviour in relation to the clinician-patient alliance. This article reports on the forensic mental health clinicians experiences of the clinician-patient alliance during mechanical restraint, and their assessment of parameters of alliance regarding the patient’s readiness to be released from restraint. We used a qualitative, descriptive approach and conducted focus group interviews with nurses, nurse assistants and social and healthcare assistants. The results show that a pre-established personal clinician-patient alliance formed the basis for entering into, and weighing the quality of, the alliance during mechanical restraint. In consideration of the patient’s psychiatric condition, the clinicians observed and assessed two quality parameters for the alliance: ‘the patient’s insight into or understanding of present situation’ (e.g. the reasons for mechanical restraint and the behaviour required of the patient to discontinue restraint) and ‘the patient’s ability to have good and stable contact and cooperation with and across clinicians. These assessments were included, as a total picture of the quality of the alliance with the patient’, in the overall team assessment of the patient’s readiness to be released from mechanical restraint. The results contribute to inform the development of a short-term risk assessment instrument, with the aim of reducing the duration of mechanical restraint.

Evidence suggests the prevalence and duration of mechanical restraint are particularly high among forensic psychiatric inpatients. However, only sparse knowledge exists regarding the reasons for, and characteristics of, prolonged use of mechanical restraint in forensic psychiatry. This study therefore aimed to investigate prolonged episodes of mechanical restraint on forensic psychiatric inpatients. Documentary data from medical records were thematically analyzed. Results show that the reasons for prolonged episodes of mechanical restraint on forensic psychiatric inpatients can be characterized by multiple factors: “confounding” (behavior associated with psychiatric conditions, substance abuse, medical noncompliance, etc.), “risk” (behavior posing a risk for violence), and “alliance parameters” (qualities of the staff-patient alliance and the patients’ openness to alliance with staff), altogether woven into a mechanical restraint spiral that in itself becomes a reason for prolonged mechanical restraint. The study also shows lack of consistent clinical assessment during periods of restraint. Further investigation is indicated to develop an assessment tool with the capability to reduce time spent in mechanical restraint.

The MR-CRAS project

Development of the MR-CRAS (Mechanical Restraint – Confounding-Risk-Alliance-Score) and validation of its measurement properties among forensic psychiatric staff and experts)

Method Supervisor: Per Bech, PhD, Clinical Professor, Institute of Clinical Medicine, University of Copenhagen, Head of Research, Dept. of Psychiatry Hillerød, The Capital Region of Denmark

English abstract

Background: The duration of mechanical restraint (MR) is particular prolonged among forensic psychiatric inpatients. Use of a risk assessment instrument during use of coercive measures has shown promising results in reducing the duration. However, no instruments exist for use during MR to support the clinical decision-making among staff on whether the patient are ready to be loosened from MR with the aim of reducing the duration of MR.

Design: Phase 1 serves to develop a version of the MR-CRAS instrument through a methodological, theoretical and empirically conceptualization based on existing literature, the guidelines and content of a selected sample of risk assessment instruments as well as planned focus group interviews among purposively sampled clinical experts with rich first-hand experience in MR. Phase 2 serves to pre-evaluate MR-CRAS through 1) face validation among purposively sampled clinical experts within forensic psychiatry; 2) content validation of the items in MR-CRAS by a purposively sampled panel of 8-12 researchers and clinical experts within the field; 3) Pilot testing of the instrument among staff within two convenience sampled forensic psychiatric inpatient units. Phase 3 serves to evaluate further measurement properties of the MR-CRAS instrument through a multicenter descriptive correlation study among staff within purposively sampled forensic psychiatric inpatient units during a period of one year. The purpose is to gain insight into the dimensionality and functionality of MR-CRAS and deciding on the definitive selection of items though relevant analysis.

Implications: The results will provide a foundation for further testing of the reliability, predictive validity etc. of the MR-CRAS and for implementing the MR-CRAS as a valid and reliable risk assessment instrument during MR. The results will also open for validation and implementation in other psychiatric settings where MR is used, both nationally and internationally. In future clinical practice, MR-CRAS as a short-term structured risk assessment scheme could be an effective element in a SPJ approach during MR. Use of MR-CRAS in a structured professional judgement process would promote systematic and transparent risk assessment, yet be flexible enough to account for case-specific influences and the context in which the assessment are made. MR-CRAS will expand the traditional preventive use of short-term risk assessment with a unique framework for use during MR.

Funding: Psychiatric Research Fond, Region of Southern Denmark.University College of Southern Denmark